Introduced around 2007 in the U.S.

Battery-powered device that looks like a cigarette and delivers an aerosol to the user

Most designed to mimic cigarettes

Most claim to contain nicotine, and some claim to sell nicotine-free cartridges

Come in a variety of flavors and nicotine levels

Aerosol is inhaled by smokers when they draw on the device, as they would a regular cigarette

Reached the U.S. market in 2007 Inhaled aerosol from e-cigarettes has

brought about the term “vaping” for the use of e-cigarettes

Users call themselves vapers A nationwide community of vapers has

formed through online forums and even national vaping conventions

E-liquid or Juice Atomizers (attys) Cartomizers (carts) Blanks Priming and switches Dripping PVs and mods Volts

Low-resistance atomizers

Pass through Goose necks

Vapor Pen

Glassomizer

Hookah pen or E-hookah

E-cigar

E-pipe

PVs or Mods

E.N.D.S.

E-cigarette

Battery Atomizing device (heating element) Liquid-filled cartridge

Tobacco products Aerosol contains nicotine and other

potentially harmful constituents Unregulated ~ 466 brands Over 7,000 unique flavors Range of players 1.5 – 2 billion in annual sales

2009 Family Smoking Prevention and Tobacco Control Act (a.k.a. Tobacco Control Act)

Gave the U.S. Food and Drug Administration (FDA) the authority to regulate tobacco products

FDA launched the Center for Tobacco Products to oversee the implementation of the Tobacco Control Act

› April, 2011: FDA announced they would regulate e-cigarettes as tobacco products under the Tobacco Control Act, but so far this has not happened

› May, 2014: FDA releases proposed deeming rule to regulate additional tobacco products

› May, 2016: FDA finalized rule extending its authority to all tobacco products, effective 8/5/16

Includes a set of automatic requirements for products containing nicotine or tobacco: › Registering manufacturers and providing

product listings› Reporting ingredients, including harmful and

potentially harmful constituents› Requiring premarket review and

authorization of new products› Health warnings on product packages› Not selling modified risk products unless

authorized

Missed opportunities: › Flavored Tobacco Products › Television Advertising › Internet Sales › Brand Name Sponsorship › Self-Service Displays › Minimum Package Size › Child-Resistant Packaging

Clinical studies about the safety and efficacy of e-cigarettes have not been submitted to the FDA

At present, consumers have no way of knowing:› The safety of the products› What types or concentrations of potentially

harmful chemicals or what dose of nicotine they are inhaling when they use e-cigarettes

2009: Preliminary analysis of ingredients in a sample of e-cigarettes:

All but one cartridge marked as having no nicotine contained nicotine

Cartridges marked as having low, medium, or high amounts of nicotine actually had varying amounts

Found a toxic antifreeze ingredient, diethylene glycol

The devices emitted “tobacco-specific nitrosamines” which are human carcinogens

The devices emitted “tobacco-specific impurities suspected of being harmful to humans”

Nielsen data from 2011-2013, 12-17 and 18-24 year olds

E-cigarette TV ad exposure has increased dramatically form 2011-2013 › Youth: 256% increase › Young Adults: 321% increase

76% of all youth e-cigarette advertising exposure occurred on cable networks (e.g., Comedy Central, AMC, TV Land, WGN )

81.7% of youth ecig ad exposures were for Blu e-cigs

Duke et al., 2014 Pediatrics (doi: 10.1542/peds.2014-0269)

49.2%

9.8%3.6%

14.5%

68.0%

14.8%4.0%

16.4%

0%10%20%30%40%50%60%70%80%90%

100%

Current Smoker Former Smoker Never SmokedCigarettes

Overall

2013 IATS 2015 IATS

1.3%3.9%5.2%

15.6%

0%

5%

10%

15%

20%

Middle School* High School*

2012 2014

*Statistically significant increase between 2012 and 2014.

Nicotine is highly addictive Nicotine may cause adverse cardiovascular effects

(increased HR, BP) and may impair endothelial function› Likely less harmful than nicotine delivered via combustion

Accidental poisoning, especially in children› E-cigarette liquid typically contains 6-36 mg nicotine per mL

Lethal adult oral dose (40-60 mg); in children, 6 mg may be life-threatening

› Calls to U.S. Poison Control Centers for e-cigarette liquid exposures increased 733% from 2012 to 20141

1American Association of Poison Control Centers https://aapcc.s3.amazonaws.com

E-cigarette & Liquid Nicotine Reported Exposures to U.S. Poison Centers (2011-2015)

271460

1,543

3,783

3,158

0

1000

2000

3000

4000

2011 2012 2013 2014 2015

*

Source: American Association of Poison Control Centershttps://aapcc.s3.amazonaws.com/files/library/E-cig__Nicotine_Web_Data_through_11.2015_gJzwy6j.pdf

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*Estimated

In 2014, there were 466 distinct brands of ENDS and more than 7,764 unique flavors1

Flavors deemed by the Flavor & Extract Manufacturers Association (FEMA) “generally recognized as safe” for oraluse cannot be deemed safe for inhalation2

Diacetyl or acetyl propionyl (impart buttery/fruity/cocoa flavor) found in ~75% of sweet-flavored e-cigarette liquids—many samples exceeded NIOSH safety limits3,4

Diacetyl, while deemed safe for ingestion by FEMA and FDA, has been shown to cause bronchiolitis obliterans(“pop-corn lung”) when inhaled

1 Zhu et al., Tob Control 2014;23(Suppl 3):iii3-iii9.2 Tierney et al., Tob Control 2015; April 15. [Epub ahead of print]3 Farsalinos et al., Nicotine Tob Res 2015;17:168–174.4 Allen et al., Environ Health Perspect 2015; Dec 8. [Epub ahead of print]

E-cigarette liquids contain small amounts of nitrosamines

E-cigarette aerosols contain the following carcinogens

› Formaldehyde› Acetaldehyde› Acrolein

Levels of most substances lower than found in tobacco smoke

No safe level of exposure has been determined

With intense heating (tank models with increased voltage), higher amounts of formaldehyde and acetaldehyde are generated—similar to concentrations in tobacco smoke3

1 Bhatnagar et al., Circulation 2014;130:1418–1436.2 Goniewicz et al., Tob Control 2014;23:133–139.3 Kosmider et al., Nicotine Tob Res 2014;16:1319–1326.

– Chromium– Nickel

Detected in Secondhand E-cigarette Aerosol :› Nicotine› Ultrafine particles› Low levels of toxins, some that are known

carcinogens, including: Acetaldehyde (MS), Benzene (SS), Cadmium (MS), Formaldehyde (MS,SS), Isoprene (SS), Lead (MS), Nickel (MS), Nicotine (MS, SS), N-Nitrosonornicotine (MS, SS), Toluene (MS, SS)

1 Bhatnagar et al., Circulation 2014;130:1418–1436.2 Schober et al., Int J Hyg Environ Health 2014:217:628-637.

Bystanders exposed to exhaled aerosol can be exposed to nicotine – have cotinine (nicotine byproduct) in their blood

Thirdhand exposure to nicotine › Result from interactions with air and

chemicals in the air › Heaviest presence on floor › Potential exposure for children - often on the

floor or touching surfaces and putting hands in their mouths

Flouris et al., 2013; Schober et al., 2014; Goniewicz and Lee, 2014

Man killed when a charging e-cigarette explodes and ignited oxygen equipment he was believe to have been using (UK; Aug 8, 2014)

RAMONA, CA: A man was hospitalized and in critical condition with burns to his face after an electronic cigarette exploded (Feb 9, 2015)

“E-cigarette blast nearly blew my legs off” after e-cigarette EXPLODES ‘like a grenade’ (UK; Oct 13, 2014)

MIAMI, FL: A Naples area man is in a medically induced coma at a Miami hospital after an e-cigarette blew up in his face (Oct 27, 2015)

E-cigarette explodes in Bentonville, Arkansas man’s face (Nov 10, 2015)“Blood just pouring down,” E-cig explodes in Oklahoma man’s face (Dec 8,

2015)Grand Rapids, MI: “I’d rather have lung cancer”: E-cigarette battery explodes

in man’s pocket and leaves him with 2nd and 3rd degree burns on his leg (Dec 9, 2015)

“Health warning: Now e-cigarettes can give you malware. Better for your lungs, worse for your hard drives, e-cigarettes can potentially infect a computer if plugged into charge” (Nov 21, 2014)

“E-cigarettes have become the latest vector for hackers to distribute malicious software. E-cigarettes manufactured in China are reportedly being used to spread malware via a USB port to computers when users plug in for charging.”

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Public Health Service Clinical PracticeGuideline: Treating Tobacco Use andDependenceKey recommendations:

--encourage all patients to quit--individual, group and telephone counseling--practical counseling and social support--ensure access to Quitline--prescribe 7 first line medications

Comprehensive smoke-free air policies› Cover all workplaces and public places,

including restaurants, bars, private and fraternal clubs, and gaming areas

› Offer full protection from secondhand smoke Raising tobacco prices

› Raise the price on cigarettes and other tobacco products equally

› Match cigarette and other tobacco product prices

Fund state tobacco control programs in accordance with the 2014 CDC Best Practices for Comprehensive Tobacco Control › Use tobacco industry settlement payments › Dedicate a small portion of what states

collect in tobacco tax revenue› Use a combination of both

NIOSH published a report last month recommending that all workplaces become tobacco-free and employers make tobacco cessation programs available to workers.

This report also includes e-cigarettes and is aimed at protecting workers from the occupational hazards of tobacco, secondhand smoke, and emissions from e-cigs.

Current Intelligence Bulletin 67: Promoting Health and Preventing Disease and Injury Through Workplace Tobacco Policies

What can health care providers do? Provide proven NRT and other tobacco

cessation treatments› Public Health Service Clinical Practice Guideline:

Treating Tobacco Use and Dependence

Ask, advise and refer (refer patients to the Indiana Tobacco Quitline)

What can health care providers do? Join the Quit Now Preferred Provider

Network› Gives health care providers proven,

professional resources to help patients/clients quit tobacco use

› Fax refer patients to the Quitline and receive status reports

› Receive ongoing communication on the latest research and tobacco news in Indiana

› Direct access to cessation specialists

1,067,735 current smokers = 21.9% of the population

Annual cost to Indiana society:between $3.6 and $6.2 Billion

(incl. medical expenses, lost productivity and years of potential life lost)

Indiana’s Most Significant Health Savings Opportunity:

Visit www.quitnowindiana.com for more information

Over 200 state and local laws restrict e-cigarette use

In Indiana: Greenwood, Hancock County, Indianapolis and South Bend* smoke-free air laws also prohibit e-cigarette use › More info on local laws in Indiana on our

website: www.isdh.in.gov/tpc

*South Bend law goes into effect January 2, 2017.

House Enrolled Act 1225 (Sale of e-cigarettes to minors):› Prohibits the sale of e-cigarettes to youth

(less than 18 years of age)› Regulates display of e-cigarettes in vending

machines› Prohibits self-service display of e-cigarettes in

areas where youth are permitted› Prohibits possession and use of e-cigarettes

for youth (less than 18 yrs)

Senate Enrolled Act 463› Requires e-cigarette retailers to obtain a

tobacco retail license › Establishes manufacturing standards› Requires childproof caps and tamper

evident packaging

The FDA and other national health organizations have warned about the potential health risks

ENDS are not currently regulated The safety of these products is virtually unknown ENDS are not proven smoking cessation aids Proven cessation treatments include proactive

tobacco quitlines and the seven first line medications approved by the FDA

More research on the safety and efficacy of these products is needed

Katelin RyanDirector of Program EvaluationISDH Tobacco Prevention and Cessation CommissionKaRyan@isdh.in.gov317-234-1783